Four cases of cough fracture.

IN the past seven years four cases of cough fracture with eight fractures were found at Killadeas Hospital and the Chest Clinic, Erne Hospital, Enniskillen. No previous record of cough fracture of a rib in Northern Ireland is known to the writer. Yet any patient with a history of cough followed by pleuritic pain may be suffering from one. Other conditions predisposing to fracture may also be present. Stress fracture is commoner than cough fracture. Unlike cough fracture it usually occurs in the first rib. As the name implies, the cause is muscular strain. Two cases with stress fracture of the first rib and one of the tenth were described in the Ulster Medical Journal ten years ago (Warmington, 1956). A typical example was encountered recently in a physical training instructress. "Fatigue fracture" of the first rib is merely a form of stress fracture affecting hitch-hikers and others who for long distances carry a heavy ruck-sack by a strap over the shoul&er (Shanks and Kerley, 1962). Stress fracture of the first rib is often asymptomatic and is usually of little clinical importance. Cough fracture is easily overlooked. The symptoms are those of the resulting pleurisy. Pleural effusion often follows. Pneumonitis may be mimiced or haemoptysis occur due to bruising or puncture of the lung by the rib ends (Shanks and Kerley, 1962). Pneumothorax or haemopneumothorax may distract attention from the underlying fracture. Also cough fracture usually affects the lower ribs in the axilla. Here rib curvature and tissue density are greatest on a postero-anterior X-ray and combine to obscure a fractured rib. For this reason Shanks and Kerley (1962) state that two oblique films are essential in every radiological investigation of rib fracture from whatever cause. Frequently separation of the fragments in cough fracture is so slight that a fracture is not seen until several weeks after symptoms have disappeared, when callus draws attention to it.